Treating dangerous patients who represent a risk to themselves or others can often trigger worrisome ethical issues—What constitutes a reportable danger? Does a specific person have to be threatened? How specific does the threat have to be? Who must be informed of the threat? These are common but complex issues that are frequently discussed in ethical consults with AAMFT’s Ethics and Legal Affairs staff—but won’t be covered under this article’s purview. Instead, we look at what happens after a threat (reportable or not) that causes you to consider terminating a relationship with your client, which invokes other ethical obligations on the part of a practitioner, specifically AAMFT Code of Ethics Section 1.11: Non-Abandonment.
It will come as no surprise that mental health practitioners occasionally encounter individuals who have the means and the intent to present as a danger to themselves or others. Some practitioners may dedicate themselves to working with patients who have severe health conditions and experience frequent, violent outbursts or violent ideation. Some therapists may not specialize in treating these populations, but can still encounter seemingly stable and well-adjusted patients with severe suicidal impulses and a means to carry them out.
It is not within the scope of AAMFT’s ethical guidelines to tell when you should terminate a relationship (except in cases where you feel that the care required to assist the client is beyond your scope of competence or experience) and termination is a personal and clinical decision each practitioner can make for themselves; although consultations with peers and supervisors may be helpful resources in making this decision. It is not the intention of the ethics guidelines to force members to continue practice in situations where they are unsafe—there is no guidance for example, that says “If the client only threatened you with a knife but never pulled it out” you must continue with all regularly scheduled appointments.
Whatever the reason for deciding to terminate a therapist-client relationship, you must take several steps to ensure compliance with ethical standards.
First and foremost, a client should be notified of the pending termination. Even in contentious situations where a practitioner is worried for their safety and has appropriately chosen to cancel an upcoming appointment, informing the client of termination is required. If unable to meet and discuss termination in person, review the client’s past disclosure form or confirm with a client that a letter can be sent to the address where the client usually receives mail, and send a letter outlining the reasons for termination and the decision. Document the process of informing the client and keep copies of any letters sent for your records (Legal Guidelines for Family Therapists, p. 41). Follow or establish a security protocol for meeting with dangerous clients.
Secondly, when headed into the termination decision, be prepared with referrals, assessed based on client’s requisite levels of care and location. Practitioners should review recent and ongoing clinical notes to determine if a client should be referred to intensive outpatient, inpatient, or a provider with different experience or specializations. Provide multiple options for care if available in your client’s region. Offer to ease the transition—extend a window of time during which the client can consult with you (in person, virtually, or over the telephone) during the transition period. Be ready with an explanation for the termination, sometimes as simple as explaining that you believe that the client’s treatment needs surpass your abilities, and that treatment with you will not improve the client’s well-being and you are ethically bound to refer them elsewhere (AAMFT Code of Ethics Section 1.11).
Knowing in advance of a termination what and to whom further disclosures must be made even when the therapist-client relationship has ceased can help avoid pitfalls with abandonment or malpractice and a suicidal patient.
Finally, be aware that in cases where termination occurs during a period where the client is at risk of suicide, many jurisdictions and state laws will allow, and in some cases, require, a disclosure of such risk. In addition, practitioners could be subject to malpractice suits if no disclosure is made and a client subsequently suffers from self-inflicted harm. Knowing in advance of a termination what and to whom further disclosures must be made even when the therapist-client relationship has ceased can help avoid pitfalls with abandonment or malpractice and a suicidal patient.
Once again, it is not the intention of the Code to dictate when a therapist can or cannot ethically terminate treatment with a dangerous client, but rather to provide structure for how the termination should be handled to ensure the safety and wellbeing of all parties and facilitate a continuum of care. Having a policy on terminating dangerous clients outlining provider responsibilities, requirements, and procedures for termination can help practitioners navigate the “what-next” of a dangerous client.
Members with further questions on terminating a contentious relationship can always book an ethics consultation on AAMFTs website or email ethics@aamft.org.
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